Outcomes of advanced care management in home-based long-term care: A retrospective population-based observational study.

BACKGROUND: In home-based long-term care, care management aims to facilitate the independence of community-dwelling older adults and mitigate the escalation of their care needs. We examined the association between the types of care management (advanced vs. conventional) and the progression of care needs among recipients with moderate care needs and compared care services offered in care plans between care management types. METHODS: A retrospective, population-based observational study was conducted in Tsukuba City in Japan. The individual-level secondary data from the suburban municipal government was collected between May 2015 and March 2019. The primary outcome was the progression of care-need levels certificated in Japanese long-term care insurance. The exposure variable was advanced care management. First, we conducted propensity-score matching to adjust for differences in recipient characteristics. Second, we performed Kaplan-Meier survival analyses and log-rank tests, with the outcome measure being the progression of care-need levels. Third, Pearson's chi-square tests were performed to compare care services for recipients of advanced vs. conventional care management. RESULTS: Of the 1010 long-term care recipients, we selected 856 propensity score-matched recipients receiving advanced or conventional care management. The proportions of four-year cumulative progression-free survival in the groups receiving advanced and conventional care management were 82.2 % and 78.5 %, respectively (p = .69). The proportions of the groups with advanced and conventional care management were 17.1 % and 23.8 % using home-help services (p < .05), and 4.0 % and 8.2 % using community-based day care services (p < .05), respectively. CONCLUSIONS: Advanced care management in home-based long-term care was not associated with a slowing of the progression of care needs among older adults with moderate care needs compared with conventional care management. There was a notable discrepancy in the use of care services, with the advanced care management group having lower rates of use of home-help services and community-based day care services compared with the conventional care management group.

Comparison of machine-learning and logistic regression models for prediction of 30-day unplanned readmission in electronic health records: A development and validation study.

It is expected but unknown whether machine-learning models can outperform regression models, such as a logistic regression (LR) model, especially when the number and types of predictor variables increase in electronic health records (EHRs). We aimed to compare the predictive performance of gradient-boosted decision tree (GBDT), random forest (RF), deep neural network (DNN), and LR with the least absolute shrinkage and selection operator (LR-LASSO) for unplanned readmission. We used EHRs of patients discharged alive from 38 hospitals in 2015-2017 for derivation and in 2018 for validation, including basic characteristics, diagnosis, surgery, procedure, and drug codes, and blood-test results. The outcome was 30-day unplanned readmission. We created six patterns of data tables having different numbers of binary variables (that ≥5% or ≥1% of patients or ≥10 patients had) with and without blood-test results. For each pattern of data tables, we used the derivation data to establish the machine-learning and LR models, and used the validation data to evaluate the performance of each model. The incidence of outcome was 6.8% (23,108/339,513 discharges) and 6.4% (7,507/118,074 discharges) in the derivation and validation datasets, respectively. For the first data table with the smallest number of variables (102 variables that ≥5% of patients had, without blood-test results), the c-statistic was highest for GBDT (0.740), followed by RF (0.734), LR-LASSO (0.720), and DNN (0.664). For the last data table with the largest number of variables (1543 variables that ≥10 patients had, including blood-test results), the c-statistic was highest for GBDT (0.764), followed by LR-LASSO (0.755), RF (0.751), and DNN (0.720), suggesting that the difference between GBDT and LR-LASSO was small and their 95% confidence intervals overlapped. In conclusion, GBDT generally outperformed LR-LASSO to predict unplanned readmission, but the difference of c-statistic became smaller as the number of variables was increased and blood-test results were used.

Polypharmacy and potentially inappropriate medications in older adults who use long-term care services: a cross-sectional study.

BACKGROUND: Older adults requiring care often have multiple morbidities that lead to polypharmacy, including the use of potentially inappropriate medications (PIMs), leading to increased medical costs and adverse drug effects. We conducted a cross-sectional study to clarify the actual state of drug prescriptions and the background of polypharmacy and PIMs. METHODS: Using long-term care (LTC) and medical insurance claims data in the Ibaraki Prefecture from April 2018 to March 2019, we included individuals aged ≥ 65 who used LTC services. The number of drugs prescribed for ≥ 14 days and the number of PIMs were counted. A generalized linear model was used to analyze the association between the backgrounds of individuals and the number of drugs; logistic regression analysis was used for the presence of PIMs. PIMs were defined by STOPP-J and Beers Criteria. RESULTS: Herein, 67,531 older adults who received LTC services were included. The median number of total prescribed medications and PIMs was 7(IQR 5-9) and 1(IQR 0-1), respectively. The main PIMs were loop diuretics/aldosterone antagonists (STOPP-J), long-term use of proton pump inhibitors (Beers Criteria), benzodiazepines/similar hypnotics (STOPP-J and Beers Criteria), and nonsteroidal anti-inflammatory drugs (STOPP-J and Beers Criteria). Multivariate analysis revealed that the number of medications and presence of PIMs were significantly higher in patients with comorbidities and in those visiting multiple medical institutions. However, patients requiring care level ≥1, nursing home residents, users of short-stay service, and senior daycare were negatively associated with polypharmacy and PIMs. CONCLUSIONS: Polypharmacy and PIMs are frequently observed in older adults who require LTC. This was prominent among individuals with comorbidities and at multiple consulting institutions. Utilization of nursing care facilities may contribute to reducing polypharmacy and PIMs.

Different trends in suicide rates among foreign residents in Japan and Japanese citizens during the COVID-19 pandemic.

BACKGROUND: Suicide rates in Japan have increased during the COVID-19 pandemic, and foreign residents may be more vulnerable to mental stress during such crises. Therefore, we aimed to compare the trends in suicide rates during the COVID-19 pandemic between foreign residents and Japanese citizens. METHODS: Vital statistics of Japan data from January 1, 2016 to December 31, 2021 were used to calculate quarterly sex-specific suicide rates for foreign residents and Japanese citizens. An event-study analysis was conducted to evaluate whether suicide rates during the COVID-19 pandemic increased compared to pre-pandemic estimates; foreign residents and Japanese citizens were compared using difference-in-difference-in-differences estimates. RESULTS: Between 2016 and 2021, 1,431 foreign residents and 121,610 Japanese citizens died from suicide in Japan. Although the suicide rate for foreign residents was lower than that for Japanese citizens, Korean residents, who comprise approximately half of the foreign decedents, had largely higher suicide rates than Japanese citizens. The event-study analysis indicated that suicide rates increased among foreign residents for both men and women, and continued for men by the end of 2021. In Japanese citizens, after a decline in suicide rates in the second quarter of 2020, suicide rates increased both among men and women, and lasted for women until the fourth quarter of 2021. The difference-in-difference-in-differences analyses confirmed the initial decline in the second quarter of 2020 in suicide rate only in Japanese men and women, and the persistent increase through 2021 in foreign men. CONCLUSIONS: We found differential trends in suicide rates between foreign and Japanese men and women during the COVID-19 pandemic featuring a persistent increase in foreign men. Suicide prevention measures should be focused on these high-risk subpopulations.

Clinical subtypes of older adults starting long-term care in Japan and their association with prognoses: a data-driven cluster analysis.

We aimed to identify the clinical subtypes in individuals starting long-term care in Japan and examined their association with prognoses. Using linked medical insurance claims data and survey data for care-need certification in a large city, we identified participants who started long-term care. Grouping them based on 22 diseases recorded in the past 6 months using fuzzy c-means clustering, we examined the longitudinal association between clusters and death or care-need level deterioration within 2 years. We analyzed 4,648 participants (median age 83 [interquartile range 78-88] years, female 60.4%) between October 2014 and March 2019 and categorized them into (i) musculoskeletal and sensory, (ii) cardiac, (iii) neurological, (iv) respiratory and cancer, (v) insulin-dependent diabetes, and (vi) unspecified subtypes. The results of clustering were replicated in another city. Compared with the musculoskeletal and sensory subtype, the adjusted hazard ratio (95% confidence interval) for death was 1.22 (1.05-1.42), 1.81 (1.54-2.13), and 1.21 (1.00-1.46) for the cardiac, respiratory and cancer, and insulin-dependent diabetes subtypes, respectively. The care-need levels more likely worsened in the cardiac, respiratory and cancer, and unspecified subtypes than in the musculoskeletal and sensory subtype. In conclusion, distinct clinical subtypes exist among individuals initiating long-term care.

Relationship between health checkups and cancer screenings of wives and health checkups of their husbands: A cross-sectional study in Japan.

Objectives: This study investigated the relationship between health checkups, cervical cancer screenings, and breast cancer screenings (collectively referred to as wellness examinations) of wives and health checkups of their husbands. We aimed to develop strategies to encourage wellness examinations among married individuals in Japan. Methods: This study used the 2019 Comprehensive Survey of Living Conditions, focusing on married couples aged 40-64. We analyzed the percentage of wives undergoing wellness examinations, grouped based on whether their husbands had undergone health checkups. Subsequently, multivariable modified Poisson regression analysis was performed considering sociodemographic and health-related factors. All analyses considered medical insurance of wives because wellness examination methods varied depending on medical insurance type. Results: The sample comprised 40,560 couples undergoing health checkups, 39,870 undergoing cervical cancer screening, and 39,895 undergoing breast cancer screening. Regardless of the medical insurance type of the wife, a significant positive association was observed between the wellness examination of wives and the health checkup of husbands across all age groups. After adjusting for covariates, prevalence ratios (95% confidence intervals) for wives whose husbands underwent health checkups were 2.24 (2.09-2.40) for national health insurance, 1.18 (1.16-1.21) for employee insurance (employee), and 1.53 (1.44-1.63) for employee insurance (family) for health checkups. Similar trends were observed in cervical and breast cancer screening. Conclusions: Wellness examinations of wives were associated with those of their husbands, suggesting that couples often share similar health-seeking behaviors. Hence, targeted interventions are important for couples who do not undergo wellness examinations.

Characteristics and in-hospital mortality of patients with COVID-19 from the first to fifth waves of the pandemic in 2020 and 2021 in the Japanese Medical Data Vision database.

Objectives: We aimed to describe patient characteristics, healthcare utilization, and in-hospital mortality among patients with COVID-19 in Japan across waves. Methods: Using a large-scale hospital-based database, we identified patients hospitalized for COVID-19 in the first (January-June 2020), second (June-October 2020), third (October 2020-February 2021), fourth (March-June 2021), and fifth (June-December 2021) waves. We summarized patient characteristics, healthcare utilization, and in-hospital mortality during each wave and performed multivariable logistic regression analyses for in-hospital mortality. Results: From the first to fifth waves, the number of patients (mean age ± standard deviation, years) was 2958 (61.2 ± 22.8), 7981 (55.6 ± 25.3), 18,788 (63.6 ± 22.9), 17,729 (60.6 ± 22.6), and 23,656 (51.2 ± 22.3), respectively. There were 190 (6.4%), 363 (4.5%), 1261 (6.7%), 1081 (6.1%), and 762 (3.2%) in-hospital deaths, respectively. The adjusted odds ratios for in-hospital deaths (95% confidence interval) were 0.78 (0.65-0.95), 0.94 (0.79-1.12), 0.99 (0.84-1.18), 0.77 (0.65-0.92), in the second to fifth waves, respectively, compared with the first wave. Conclusions: In-hospital COVID-19 mortality improved from the first to the second wave; however, during the third and fourth waves, mortality was as serious as in the first wave. Although in-hospital mortality during the fifth wave improved, careful monitoring is needed for upcoming waves, considering changing patient and viral characteristics.

Factors associated with non-participation in breast cancer screening: analysis of the 2016 and 2019 comprehensive survey of living conditions in Japan.

BACKGROUND: The participation rate for breast cancer screening remains to be suboptimal in Japan. Therefore, it is important to identify factors associated with non-participation and identify people at high risk for non-participation. METHODS: We carried out a cross-sectional study using the data of women aged 40-74 years from the 2016 and 2019 Comprehensive Survey of Living Conditions. We selected candidate predictor variables from the survey sheets and conducted a multivariable logistic regression for non-participation in breast cancer screening for the past 2 years. In addition, using data from 2016, we created an integer risk score for non-participation and tested its predictive performance in 2019. RESULTS: The proportion of participants in breast cancer screening in 2016 and 2019 were 46.7% (50,177/107,513) and 48.7% (49,498/101,716), respectively. In multivariable logistic regression analysis, age over 50 years, single/divorced/widowed, lower education level, lower household expenditure, being insured for National Health Insurance, employed to small/middle scale company, non-regularly employed, current smoker, never/quit drinking or middle/high-risk drinking, lower self-rated health status, higher Kessler Psychological Distress Scale score, non-participation in the annual health checkups for diseases other than cancer, not constantly visiting hospitals/clinics showed a positive association with non-participation. The 9-item risk score (age, marital status, education, health insurance plan, employment, smoking, drinking, non-participation in the annual health checkups for diseases other than cancer, and not constantly visiting hospitals/clinics) and 3-item risk score (age, health insurance plan, non-participation in the annual health checkups for diseases other than cancer) showed the area under the receiver operating characteristic curve of 0.744 and 0.720, respectively. CONCLUSION: We identified factors associated with non-participation in breast cancer screening. The simple risk score would be useful for public health sectors to identify people at risk for non-participation.

Factors associated with non-initiation of osteoporosis pharmacotherapy after hip fracture: analysis of claims data in Japan.

In an analysis of claims data from a city in Japan, male patients and patients with dementia were less likely to receive osteoporosis pharmacotherapy after hip fracture. Treatment initiation rate has improved between 2014 and 2017. PURPOSE: Older adults with recent hip fractures are at a high risk of recurrent fractures. However, the post-fracture care gap has been reported globally. This study examines factors associated with pharmacotherapy non-initiation within 1 year after hip surgery. METHODS: Using medical and long-term care (LTC) claims, and LTC needs certification data in Tsukuba City, Japan, we identified individuals aged 65 years or older who had hip fractures with subsequent surgical procedures between October 1, 2014, and December 31, 2017. Patient (age, sex, dementia, and comorbidities) and health service-related characteristics (fiscal year, type of hospital, number of hospital beds, and admission to recovery phase rehabilitation wards) were examined. The association of these factors with non-pharmacotherapy for osteoporosis within 1 year after hip fracture using multivariable logistic models was analyzed. RESULTS: We identified 275 patients with hip fractures who did not receive pharmacotherapy pre-fracture. Forty percent of them received pharmacotherapy within 1 year of post-fracture. Male sex (odds ratio (OR) = 4.49 [2.14-9.44]) and dementia (OR = 1.90 [1.03-3.52]) were associated with no pharmacotherapy, whereas later fiscal year (OR = 0.64 [0.48-0.87]) and admission to rehabilitation wards (OR = 0.25 [0.14-0.46]) were associated with pharmacotherapy initiation within 1 year of post-fracture. Comorbidities were not associated with the initiation of pharmacotherapy. CONCLUSION: Pharmacotherapy for osteoporosis was less likely to be initiated after a hip fracture in male patients and patients with dementia. These patients should be considered for pharmacotherapy because they are at high risk of recurrent fractures.

Hospital-Level Variation in Cardiac Rehabilitation After Myocardial Infarction in Japan During Fiscal Years 2014-2015 Using the National Database.

Background: Cardiac rehabilitation (CR) is an evidence-based medical service for patients with acute myocardial infarction (AMI); however, its implementation is inadequate. We investigated the provision status and equality of CR by hospitals in Japan using a comprehensive nationwide claims database. Methods and Results: We analyzed data from the National Database of Health Insurance Claims and Specific Health Checkups in Japan for the period April 2014-March 2016. We identified patients aged ≥20 years with postintervention AMI. We calculated hospital-level proportions of inpatient and outpatient CR participation. The equality of hospital-level proportions of inpatient and outpatient CR participation was evaluated using the Gini coefficient. We included 35,298 patients from 813 hospitals for the analysis of inpatients and 33,328 patients from 799 hospitals for the analysis of outpatients. The median hospital-level proportions of inpatient and outpatient CR participation were 73.3% and 1.8%, respectively. The distribution of inpatient CR participation was bimodal; the Gini coefficients of inpatient and outpatient CR participation were 0.37 and 0.73, respectively. Although there were statistically significant differences in the hospital-level proportion of CR participation for several hospital factors, CR certification status for reimbursement was the only visually evident factor affecting the distribution of CR participation. Conclusions: The distributions of inpatient and outpatient CR participation by hospitals were suboptimal. Further research is warranted to determine future strategies.

Pulse Methylprednisolone Versus Dexamethasone in COVID-19: A Multicenter Cohort Study.

Although pulse (high-dose) methylprednisolone therapy can hypothetically control immune system flare-ups effectively, the clinical benefit of pulse methylprednisolone compared with dexamethasone in COVID-19 remains inconclusive. OBJECTIVES: To compare pulse methylprednisolone to dexamethasone as a COVID-19 treatment. DESIGN SETTING AND PARTICIPANTS: Using a Japanese multicenter database, we identified adult patients admitted for COVID-19 and discharged between January 2020 and December 2021 treated with pulse methylprednisolone (250, 500, or 1,000 mg/d) or IV dexamethasone (≥ 6 mg/d) at admission day 0 or 1. Main Outcomes and Measures: The primary outcome was in-hospital mortality. Secondary outcomes were 30-day mortality, new ICU admission, insulin initiation, fungal infection, and readmission. Multivariable logistic regression was conducted to differentiate the dose of pulse methylprednisolone (250, 500, or 1,000 mg/d). Additionally, subgroup analyses by characteristics such as the need for invasive mechanical ventilation (IMV) were also conducted. RESULTS: A total of 7,519, 197, 399, and 1,046 patients received dexamethasone, 250, 500, and 1,000 mg/d of methylprednisolone, respectively. The crude in-hospital mortality was 9.3% (702/7,519), 8.6% (17/197), 17.0% (68/399), and 16.2% (169/1,046) for the different doses, respectively. The adjusted odds ratio (95% CI) was 1.26 (0.69-2.29), 1.48 (1.07-2.04), and 1.75 (1.40-2.19) in patients starting 250, 500, and 1,000 mg/d of methylprednisolone, respectively, compared with those starting dexamethasone. In subgroup analyses, the adjusted odds ratio of in-hospital mortality was 0.78 (0.25-2.47), 1.12 (0.55-2.27), and 1.04 (0.68-1.57) in 250, 500, and 1,000 mg/d of methylprednisolone, respectively, among patients with IMV, whereas the adjusted odds ratio was 1.54 (0.77-3.08), 1.62 (1.13-2.34), and 2.14 (1.64-2.80) among patients without IMV. CONCLUSIONS AND RELEVANCE: Higher doses of pulse methylprednisolone (500 or 1,000 mg/d) may be associated with worse COVID-19 outcomes when compared with dexamethasone, especially in patients not on IMV.

Evaluation of enhanced home care support clinics regarding emergency home visits, hospitalization, and end-of-life care: a retrospective cohort study in a city of Japan.

BACKGROUND: To meet the increasing demand for home healthcare in Japan as the population ages, home care support clinics/hospitals (HCSCs) and enhanced HCSCs were introduced in 2006 and 2012, respectively. This study aimed to evaluate whether enhanced HCSCs fulfilled the expected role in home healthcare. METHODS: We conducted a retrospective cohort study using linked medical and long-term care claims data from a municipality in Japan. Participants were ≥ 65 years of age, had newly started regular home visits between July 2014 and March 2018, and used either conventional or enhanced HCSCs. Patients were followed up for one year after they started regular home visits or until the month following the end of the regular home visits if they ended within one year. The outcome measures were (i) emergency home visits at all hours and on nights and holidays at least once, respectively, (ii) hospitalization at least once, and (iii) end-of-life care, which was evaluated based on the place of death and whether a physician was present at the time of in-home death. Multivariable logistic regression analyses were conducted for the outcomes of emergency home visits and hospitalizations. RESULTS: The analysis included 802 patients, including 405 patients in enhanced HCSCs and 397 patients in conventional HCSCs. Enhanced HCSCs had more emergency home visits at all hours than conventional HCSCs (65.7% vs. 49.1%; adjusted odds ratio 1.70, 95% CI [1.26-2.28]), more emergency home visits on nights and holidays (33.6% vs. 16.7%; 2.20 [1.55-3.13]), and fewer hospitalizations (21.5% vs. 32.2%; 0.55 [0.39-0.76]). During the follow-up period, 229 patients (152 patients in enhanced HCSCs and 77 patients in HCSCs) died. Deaths at home were significantly more common in enhanced HCSCs than in conventional HCSCs (80.9% vs. 64.9%; p < .001), and physician-attended deaths among those who died at home were also significantly more common in enhanced HCSCs (99.2% vs. 78.0%; p < .001). CONCLUSIONS: This study confirms that enhanced HCSCs are more likely to be able to handle emergency home visits and end-of-life care at home, which are important medical functions in home healthcare. Further promotion of enhanced HCSCs would be advantageous.

Association between types of home healthcare and emergency house calls, hospitalization, and end-of-life care in Japan.

BACKGROUND: To meet the increasing demand for home healthcare in Japan, as part of the national healthcare system, home care support clinics/hospitals (HCSCs) and enhanced HCSCs were introduced in 2006 and 2012 respectively. This study aimed to evaluate whether HCSCs has succeeded in providing 24-h home care services through the end of life. METHODS: A retrospective cohort study was conducted using the national database in Japan. Participants were ≥ 65 years of age, had newly started regular home visits between July 2014 and September 2015, and used general clinics, conventional HCSCs, or enhanced HCSCs. Each patient was followed up for 6 months after the first visit. The outcome measures were (i) emergency house call(s), (ii) hospitalization(s), and (iii) end-of-life care defined as in-home death. Multivariable logistic regression analyses were performed for statistical analysis. RESULTS: The analysis included 160,674 patients, including 13,477, 64,616, and 82,581 patients receiving regular home visits by general clinics, conventional HCSCs, and enhanced HCSCs respectively. Compared to general clinics, the use of conventional and enhanced HCSCs was associated with an increased likelihood of emergency house calls (adjusted odds ratio [aOR] and 95% confidence intervals [CIs] of 1.62 [1.56-1.69] and 1.86 [1.79-1.93], respectively) and a decreased likelihood of hospitalizations (aOR [95% CIs] of 0.86 [0.82-0.90] and 0.88 [0.84-0.92] respectively). Among 39,082 patients who died during the follow-up period, conventional and enhanced HCSCs had more in-home deaths (aOR [95% CIs] of 1.46 [1.33-1.59] and 1.60 [1.46-1.74], respectively) compared to general clinics. CONCLUSIONS: HCSCs (especially enhanced HCSCs) provided more emergency house calls, reduced hospitalization, and enabled expected deaths at home, suggesting that further promotion of HCSCs (especially enhanced HSCSs) would be advantageous.

The Effect of Home Care Support Clinics on Hospital Readmission in Heart Failure Patients in Japan.

BACKGROUND: Heart failure is common and is associated with high rates of hospitalization. Home care support clinics/hospitals (HCSCs) and enhanced HCSCs were introduced in Japan in 2006 and 2012, respectively. OBJECTIVE: This study aimed to examine the effect of post-discharge care by conventional or enhanced HCSCs on readmission, compared with general clinics. DESIGN: Retrospective cohort study using the Japanese nationwide health insurance claims database. PARTICIPANTS: Participants were ≥65 years of age, admitted for heart failure and discharged between July 2014 and August 2015 and received a home visit within a month following the discharge (n=12,393). MAIN MEASURES: The exposure was the type of medical facility that provides post-discharge home healthcare: general clinics, conventional HCSCs, and enhanced HCSCs. The primary outcome was all-cause readmission for 6 months after the first visit; the incidence of emergency house calls was a secondary outcome. We used a competing risk regression using the Fine and Gray method, in which death was regarded as a competing event. KEY RESULTS: At 6 months, readmissions were lower in conventional (38%) or enhanced HCSCs (38%) than general clinics (43%). The adjusted subdistribution hazard ratio (sHR) of readmission was 0.87 (95% CI: 0.78-0.96) for conventional and 0.86 (0.78-0.96) for enhanced HCSCs. Emergency house calls increased with conventional (sHR: 1.77, 95% CI:1.57-2.00) and enhanced HCSCs (sHR: 1.93, 95% CI: 1.71-2.17). CONCLUSIONS: Older Japanese patients with heart failure receiving post-discharge home healthcare by conventional or enhanced HCSCs had lower readmission rates, possibly due to compensation with more emergency house calls. Conventional and enhanced HCSCs may be effective in reducing the risk of rehospitalization. Further studies are necessary to confirm the medical functions performed by HCSCs.

Development and validation of a risk score to predict the frequent emergency house calls among older people who receive regular home visits.

BACKGROUND: The demand for home healthcare is increasing in Japan, and a 24-hour on-call system could be a burden for primary care physicians. Identifying high-risk patients who need frequent emergency house calls could help physicians prepare and allocate medical resources. The aim of the present study was to develop a risk score to predict the frequent emergency house calls in patients who receive regular home visits. METHODS: We conducted a retrospective cohort study with linked medical and long-term care claims data from two Japanese cities. Participants were ≥ 65 years of age and had newly started regular home visits between July 2014 and March 2018 in Tsukuba city and between July 2012 and March 2017 in Kashiwa city. We followed up with patients a year after they began the regular home visits or until the month following the end of the regular home visits if this was completed within 1 year. We calculated the average number of emergency house calls per month by dividing the total number of emergency house calls by the number of months that each person received regular home visits (1-13 months). The primary outcome was the "frequent" emergency house calls, defined as its use once per month or more, on average, during the observation period. We used the least absolute shrinkage and selection operator (LASSO) logistic regression with 10-fold cross-validation to build the model from 19 candidate variables. The predictive performance was assessed with the area under the curve (AUC). RESULTS: Among 4888 eligible patients, frequent emergency house calls were observed in 13.0% of participants (634/4888). The risk score included three variables with the following point assignments: home oxygen therapy (3 points); long-term care need level 4-5 (1 point); cancer (4 points). While the AUC of a model that included all candidate variables was 0.734, the AUC of the 3-risk score model was 0.707, suggesting good discrimination. CONCLUSIONS: This easy-to-use risk score would be useful for assessing high-risk patients and would allow the burden on primary care physicians to be reduced through measures such as clustering high-risk patients in well-equipped medical facilities.

Associations of polypharmacy and drugs with sedative or anticholinergic properties with the risk of long-term care needs certification among older adults in Japan: A population-based, nested case-control study.

AIM: To estimate the risk of disability associated with high-risk prescribing, such as polypharmacy and drugs with sedative or anticholinergic properties, using long-term care needs certification as a proxy of incident disability. METHODS: A case-control study nested within a cohort of older adults (89% aged ≥65 years) was carried out between 2014 and 2019 using the combined medical claims and long-term care needs certification database of Tsukuba City, Japan. We identified 2123 cases who received their first long-term care certification, and matched them to 40 295 controls based on age, sex, residential area and observation period (≥36 months). The risk of long-term care needs certification associated with high-risk prescribing exposure 7-30 months before the index month was estimated using conditional logistic regression adjusting for baseline comorbidities and health service use. RESULTS: Polypharmacy (5-9 drugs; adjusted odds ratio [aOR] 1.32, 95% confidence interval [95% CI] 1.18-1.47), hyperpolypharmacy (≥10 drugs; aOR 1.87, 95% CI 1.57-2.23) and cumulative dose of drugs with sedative or anticholinergic properties (1-364 defined daily dose [DDD]; aOR 1.07, 95% CI 0.97-1.19; 365-729 DDD; aOR 1.25, 95% CI 1.07-1.45; ≥730 DDD; aOR 1.33, 95% CI 1.19-1.62) had dose-response relationships with long-term care certification risks. CONCLUSIONS: High-risk prescribing was associated with the risk of long-term care needs certification in the general older population. Further studies are warranted to examine whether a decrease in prescribing drugs with sedative or anticholinergic properties could reduce the long-term care burden on society. Geriatr Gerontol Int 2022; 22: 497-504.

Medical expenditures for fragility hip fracture in Japan: a study using the nationwide health insurance claims database.

Using the nationwide health insurance claims database in Japan, we estimated total annual medical expenditures for fragility hip fracture across the population at 329.2 billion yen (2.99 billion US dollars). Long-term care expenditures were not included. Fragility hip fracture imposes a considerable health economic burden on society in Japan. PURPOSE: Fragility hip fracture imposes a substantial health economic burden on society globally. We aimed to estimate medical expenditures for fragility hip fracture using the nationwide health insurance claims database in Japan. METHODS: We included adults aged 60 and over without prior hip fracture who were admitted for fragility hip fracture (i.e., femoral neck or extracapsular) between October 2014 and October 2015 (13 months). Fragility hip fracture was identified through newly assigned disease codes for fracture and procedure codes associated with the fracture. As a proxy for medical expenditures per patient, incremental payments were calculated (i.e., the difference between the total payments 6 months before and after fragility hip fracture). The total payments included health insurance reimbursements and copayments for inpatient and outpatient services. Long-term care expenditures were not included in this study. RESULTS: We identified 142,361 individuals (28,868 male and 113,493 female) with fragility hip fracture. Mean medical expenditures for fragility hip fracture per patient were 2,550,000 yen (¥) (23,180 US dollars [$]; ¥110 = $1) in male and ¥2,494,000 ($22,670) in female patients, respectively. Total annual medical expenditures for fragility hip fracture across the population were 329.2 billion yen (2.99 billion US dollars): 67.96 billion yen (620 million US dollars) in male and 261.24 billion yen (2.37 billion US dollars) in female patients, respectively. CONCLUSION: This is the first study to estimate medical expenditures for hip fracture using the nationwide health insurance claims database, which represents almost all health insurance claims in Japan. Fragility hip fracture inflicts a considerable health economic burden on society in Japan.

Association between pre-admission anticoagulation and in-hospital death, venous thromboembolism, and major bleeding among hospitalized COVID-19 patients in Japan.

PURPOSE: The coagulation activation leads to thrombotic complications such as venous thromboembolism (VTE) in patients with coronavirus disease-2019 (COVID-19). Prophylactic anticoagulation therapy has been recommended for hospitalized COVID-19 patients in clinical guidelines. This retrospective cohort study aimed to examine the association between pre-admission anticoagulation treatment and three outcomes: in-hospital death, VTE, and major bleeding among hospitalized COVID-19 patients in Japan. METHODS: Using a large-scale claims database built by the Medical Data Vision Co. in Japan, we identified patients hospitalized for COVID-19 who had outpatient prescription data at least once within 3 months before being hospitalized. Exposure was set as pre-admission anticoagulation treatment (direct oral anticoagulant or vitamin K antagonist), and outcomes were in-hospital death, VTE, and major bleeding. We conducted multivariable logistic regression analyses, adjusting for a single summarized score (a propensity score of receiving pre-admission anticoagulation) for VTE and major bleeding, due to the small number of outcomes. RESULTS: Among the 2612 analytic patients, 179 (6.9%) had pre-admission anticoagulation. Crude incidence proportions were 13.4% versus 8.5% for in-hospital death, 0.56% versus 0.58% for VTE, and 2.2% versus 1.1% for major bleeding among patients with and without pre-admission anticoagulation, respectively. Adjusted odds ratios (95% confidence intervals) were 1.25 (0.75-2.08) for in-hospital death, 0.21 (0.02-1.97) for VTE, and 2.63 (0.80-8.65) for major bleeding. Several sensitivity analyses did not change the results. CONCLUSIONS: We found no evidence that pre-admission anticoagulation treatment was associated with in-hospital death. However, a larger sample size may be needed to conclude its effect on VTE and major bleeding.

Comparison of patient characteristics and in-hospital mortality between patients with COVID-19 in 2020 and those with influenza in 2017-2020: a multicenter, retrospective cohort study in Japan.

BACKGROUND: COVID-19 has worse mortality than influenza in American and European studies, but evidence from the Western Pacific region is scarce. METHODS: Using a large-scale multicenter inpatient claims data in Japan, we identified individuals hospitalised with COVID-19 in 2020 or influenza in 2017-2020. We compared patient characteristics, supportive care, and in-hospital mortality, with multivariable logistic regression analyses for in-hospital mortality overall, by age group, and among patients with mechanical ventilation. FINDINGS: We identified 16,790 COVID-19 patients and 27,870 influenza patients, with the different age distribution (peak at 70-89 years in COVID-19 vs. bimodal peaks at 0-9 and 80-89 years in influenza). On admission, the use of mechanical ventilation was similar in both groups (1·4% vs. 1·4%) but higher in the COVID-19 group (3·3% vs. 2·5%; p<0·0001) during the entire hospitalisation. The crude in-hospital mortality was 5·1% (856/16,790) for COVID-19 and 2·8% (791/27,870) for influenza. Adjusted for potential confounders, the in-hospital mortality was higher for COVID-19 than for influenza (adjusted odds ratio [aOR] 1·83, 95% confidence interval [CI] 1·64-2·04). In age-stratified analyses, the aOR (95%CI) were 0·78 (0·56-1·08) and 2·05 (1·83-2·30) in patients aged 20-69 years and ≥70 years, respectively (p-for-interaction<0·0001). Among patients with mechanical ventilation, the aOR was 0·79 (0·59-1·05). INTERPRETATION: Patients hospitalised with COVID-19 in Japan were more likely to die than those with influenza. However, this was mainly driven by findings in older people, and there was no difference once mechanical ventilation was started. FUNDING: Ministry of Health, Labour and Welfare of Japan (21AA2007).